Medicine’s Suicide Problem, Part 1

[Iterate]

Source:Forbes Blogs by Robert Langreth and Rebecca Ruiz Aug. 30 2010 - 9:50 am

Alexsandra Wixom started experiencing uncontrollable bouts of sadness when she was 15. “I was emotionally off. I cried all the time,” recalls the Seattle-area resident, who is now 25. Her mood swings eventually became so wild the former honors student had to quit going to high school. Over the next eight years she saw a psychiatrist every other week. Her doctors tried everything from Zoloft to mood stabilizers to heavy-duty antipsychotics, but none of them helped for long.

<snip>

Few suicidal patients get such good treatment. Roughly 35,000 Americans commit suicide each year–more than die from prostate cancer or Parkinson’s disease. Another 1.1 million people make attempts, while 8 million have suicidal thoughts. Among those aged 15 to 25 it is the third leading cause of death. Yet researchers know astonishingly little about how to treat people who contemplate killing themselves. The subject has been so roundly ignored that the 900-page bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders IV, offers no advice for doctors on how to assess suicide risk.

Fear, logistics, low research funding and more risk than reward for drug companies all conspire to make suicide the neglected disease. The National Institutes of Health is spending a paltry $40 million in 2010 studying suicide, versus $3.1 billion for research on aids, which kills half the number of Americans. (Another government agency spends $48 million on hotlines and prevention.) Therapists often don’t want to treat suicidal patients, and university clinical study review boards are skittish about studying them, says the University of Washington’s Linehan.

Big pharma routinely excludes suicidal patients from their tests of antidepressants and other drugs. There’s no commercial imperative to crawl out on that limb. Trials in at-risk patients would cost millions of dollars and could take years to perform; they might yield murky results–or worse. A suicide in the drug group could be used by competitors to destroy even a promising drug. The legal overhang is real. GlaxoSmithkline has paid $390 million to settle lawsuits related to patients who attempted or completed suicide while on Paxil, Bloomberg News estimates.

<more at link, emphasis added>

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I don't want to make this a tangential bashing of big pharma: I think we can simply stipulate that they are cowardly and narrowly self-interested.

The medical research community fares little better. Clueless, overwhelmed, and underfunded, most have chosen any other research field where they feel more immediate progress can be made. For every valuable study, there are a dozen fraught with puzzles, nonsense, and weak correlations. A few are doing pioneering work, and they will be pointed out later.

Nor is there much wisdom about the causes or prevention suicide in our culture. It would take volumes to list the myths and misconceptions. About all we can say with any certainty is that it is the result of either trauma, one of three mental illnesses, and to some degree social isolation. There are a few drugs which might be effective, otherwise the best advice is usually some version of "stay close, talk often", but neither is a guarantee.

Illness research advocacy groups are politically weak in comparison to, for example, cancer survivors groups. Frankly, I think about all the surviving relatives can manage is their own recovery, and community activism is usually beyond their reach.

I'll post the other parts in the next few days. Hope to reach more people that way.

A note to parents with children aged 18, especially those college bound:They may not legally drink and some colleges feel obliged to send you their grades, but their medical records become private at that point. You will not be informed of the diagnosis of a potentially fatal illness, an illness which by definition renders the sufferer incapable of clear thinking.

[Coyote_Bandit]

1. Thanks for posting this

I've lost 3 people to suicide in the last three months.

Two of them were an older couple (one of whom had some serious health problems) who wanted to be together forever. They must have spent many months planning and looking forward to their last day together. They attended to all their affairs (going so far as rehoming the dog, and selling their home and personal property) and made an effort not to unnecessarily traumatize their family and friends - or the folks who found their bodies. They left on a long anticipated extended trip to Europe never to return.

The other was a young father who was drunk, impulsive and expressed vengeful motives before taking his own life. If he were still alive he would regret his actions. If there was trauma it was related to domestic turmoil. If there was social isolation it was of his own choosing - although it was not something I observed. If there was mental illness I can't say I ever observed any signs of it and I knew this fellow his entire life - and knew him well. I've spent a lot of time reading about mental illness and suicide lately. I look for him in the details - but they just don't seem to fit.

[Iterate]

2. oh my

So sorry.
Of all the things to deal with, like the normal part of grieving, the living are forever left with the "why" and the "what could I have done" question. They never seem to get resolved. I suppose then that at some point we've read the same books, as there are so few. I remember reading and hearing from others that the "nearly rational" suicides are fairly rare, that often people make elaborate and fully intentional plans for both living and dying at the same time(even when the final act is impulsive). Also, people are often bizarrely considerate without, at the same time, being able to register the devastation heaped upon others. Your the words "impulse", "drink", and self-enforced isolation sound familiar as clues to an undiagnosed bipolar syndrome. I don't know, I really don't, those are all "maybe" answers.

I don't know, and that's the point, we don't know, we're left to speculate and piece together some kind of reason out of a hodgepodge of ideas, trying our best to avoid the superstition and myth of the past. Yet the medical research and treatment world seems paralyzed and hamstrung. There are no advocates for research, so that makes it a political question as well as a medical one.

[Coyote_Bandit]

3. While he was drunk at the time of his death

that father was not known to drink or use drugs. Friends and family believed it had been over 20 years since he had consumed any alcohol. He had no prior history of drug or alcohol addiction or abuse.

He didn't have a history of unstable relationships. He seemed to conduct himself well in social situations and to have regular social contacts. He was close to his parents, siblings, in-laws. Maintained friendships that dated back to childhood. Was married for 20 years. Never separated - though there was domestic turmoil at the time of his death and he had refused to seek the counseling requested by his wife. He seemed to have attachment issues and he dropped out of college because he was homesick.

I never saw indications of mood swings, mania or major or prolonged depression. No history of high risk behavior or self harm prior to taking his life. No history of mental illness among his immediate family, his grandparents, his first cousins or extended family. No history of trauma, abuse or sexual exploitation as a child.

He was intellectually gifted with a higher than average IQ and was very well read - though he despised formal education. He was not gifted with patience, persistence or the ability to pay attention to fine detail.

Sometimes he seemed immune to frustration. Other times he would explode in anger - sometimes disproportionate to the stimulus for that anger. His wife assures me that he never attempted to harm her or the children.

A tendency to be manipulative and impulsive, a desire for control and the occasional outburst of anger were character traits that were observed in early childhood.

I know there very likely are things that I don't know and didn't observe. I also know that bipolar disorder can manifest itself in many different ways. Perhaps he was bipolar. Perhaps it is easier to recognize traits of mental illness when looking back in time and seeking them out. From my reading I think that intermittent explosive disorder or borderline personality disorder might also be possible diagnoses.

Sorry to be so long. Just reciting some of the pieces of the puzzle.

[Iterate]

4. Even worse

that no one would have had warning, or a cause for concern, a chance to stop it, or now, even a way of understanding. I don't know why it's worse that having someone close die from a heart-attack or accident, but it surely is. Much worse.

It's been a while since I looked through the literature, like PubMed and such, but I do remember that the topic of impulse control comes up often. It makes sense that humans, or all primates, would have evolved such mechanisms, sometimes quick to react, sometimes slow, and that there would be not only variability within the population, but sometimes those mechanisms and feed-backs would all go wrong. The first time I had a close friend (a high school friend) die from suicide, the act itself was completely impulsive, but everyone knew he had a host of other problems (or symptoms if you want to call it that) as well. In hindsight, he must have been in the most extreme pain for a long time before he took his life.

As an aside, I noticed last week that suicides in Australia have dropped by 200 per year following a gun buy-back program that was passed into law in 1997. So it does seem that impulsiveness is significant, and if that moment of such extreme pain has a chance to pass, there's opportunity later on to recover. Now only if the researchers can give us some tests, some warning time, maybe there's a chance more people can be helped in time.

Oh, and I can be long-winded too, as well as time-zone challenged ;>

[Iterate]

5. After looking at the next parts of this article, I won't continue posting it.

I decided that it was too full of nonsense to promote further on DU.

Sure, it does have its spot-on moments, but there were just too many holes, too much ghost-in-the-machine thinking, too much "causation" derived from poorly quoted demographics. And you just shouldn't have to argue so much against your own source.

Here's an example of the research that I do think is worthwhile and was trying to promote, in this case some epigenetic studies. It brings up a few of the issues you were writing about.

"Signs of Suicide Seen in Brain Scans"
http://www.livescience.com/health/080506-suicide-epigenetics.html